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 In this model personality disorders are characterized by impairments in personality functioning and pathological personality traits  In the Alternative Model for Personality Disorders histrionic and schizoid personality disorders are excluded  In the Alternative Model Criterion A: Level of Personality Functioning and Criterion B: Pathological Personality Traits make up the diagnostic model

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Relationship to Axis I Relationship to Axis I Egosyntonic and Characterological Egosyntonic and Characterological Character traits more amenable to treatment Character traits more amenable to treatment Transference/Countertransference Transference/Countertransference Stress a variable in intensity Stress a variable in intensity

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Promote adaptive trait-based behavior Promote adaptive trait-based behavior – How and when to ask for help Create conducive environments Create conducive environments – Modify environment to match client instead of asking the client to adapt to the environment that has been problematic

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 Help them find an environment they can flourish in › Especially true with Borderline PD  Set appropriate limits  Environmental Enrichment

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 Pride is a pleasurable self-conscious emotion arising when people feel good about themselves  There appears to be two facets of the same emotion › AUTHENTIC PRIDE › HUBRISTIC PRIDE  Both are adaptive-secure social status Tracey, Jessica. “Pride and Power”. Scientific American Mind. Nov/Dec 2013, pgs

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 HUBRISTIC PRIDE (continued) › More interested in derogating others than helping them › Serves as a crutch for our sense of self › Short-term success with longer-term negative effect on relationships and mental health › Facilitates all of the behaviors needed to be dominant-arrogance, sense of superiority and willingness to intimidate and derogate others

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 We live in a world of duality by comparison › Grades › Money › Position  That perpetuates infantile narcissism (EGO)  Secondary gain of the ego  Must remove self from the race

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Symptoms of Narcissistic Personality Disorder Symptoms of Narcissistic Personality Disorder – Grandiosity – Sensitive to criticism – Lack of empathy Grandiosity is a world view that protects the EGO from experiencing the hurt, loneliness and isolation of existence. Grandiosity is a world view that protects the EGO from experiencing the hurt, loneliness and isolation of existence.

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DSM-I categorized alcoholism under antisociality DSM-I categorized alcoholism under antisociality May have associated impulse control problems May have associated impulse control problems Higher incidence of Substance-Related Disorders and Pathological Gambling Higher incidence of Substance-Related Disorders and Pathological Gambling

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 PARALIMBIC SYSTEM IS A CIRCUIT OF INTERCONECTED BRAIN REGIONS THAT MAY WELL BE THE AREA OF MALFUNCTION IN ASPD  THESE INTERCONNECTED BRAIN REGIONS REGISTER FEELINGS AND OTHER SENSATIONS AND ASSIGN EMOTIONAL VALUE TO EXPERIENCES, AS WELL AS, BEING INVOLVED IN DECISION MAKING, HIGH LEVEL REASONING AND IMPULSE CONTROL  AREA IS UNDERDEVELOPED IN ASPD AND DAMAGE TO THESE AREAS CAN CREATE PSYCHOPATHIC TRAITS

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 43 INCHES LONG, 1.25 INCHES IN DIAMETER AND WEIGHING POUNDS THE TAMPING IRON PENETRATED THE LEFT CHEEK AND EXCITING THROUGHT THE SKULL  LOST A PART OF HIS BRAIN CALLED THE VENTROMEDIAL PREFRONTAL CORTEX (VMPFC) AN AREA STRUCTURALLY SIMILAR TO THE ORBITOFRONTAL CORTEX (OFC)

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 OFC INVOLVED IN SOPHISTICATED DECISION-MAKING TASKS THAT INVOLVE SENSITIVITY TO RISK, REWARD AND PUNISHENT  LEADS TO PROBLEMS OF IMPULSIVITY AND INSIGHT AND LASH OUT IN RESPONSE TO PERCEIVED AFFRONTS  THESE WERE GAGES”S PREDOMINANT SYSMPTOMS ALTHOUGH HE STILL POSSESSED EMPATHY

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 EMPATHY INVOLVES MANY AREAS OF THE BRAIN BUT THE AMYGDALA SEEMS TO BE A CENTRAL PLAYER AS IT GENERATES EMOTIONS SUCH AS FEAR-CREATES FEARLESSNESS  ASPD NOTED FOR FEARLESSNESS-WHEN CONFRONTED WITH AN ATTACKER THEY DO NOT BLINK  THEIR EEG READINGS ARE CONSISTENT WHEN SHOWN WORDS LIKE “BLOOD” AND “HOUSE” ( A NEUTRAL WORD), THE PATTERNS ARE ALSO DIFFERENT THAN CONTROLS

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 THE ANTERIOR CINGULATE REGULATES EMOTIONAL STATES AND HELPS PEOPLE CONTROL THEIR IMPULSES AND MONITOR THEIR BEHAVIOR FOR MISTAKES  THE INSULA PLAYS A KEY ROLE IN THE RECOGNITON OF VIOLATION OF SOCIAL NORMS, AS WELL AS, THE EXPERIENCING OF ANGER, FEAR, EMPATHY AND DISGUST  INSULA ALSO INVOLVED IN PAIN PERCEPTION AND PSYCHOPATHS ARE STRIKINGLY UNFAZED BY THREAT OF PAIN

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 fMRI IMAGES OF BRAINS (KIEHL) SHOW PRONOUNCED THINNING OF PARALIMBIC TISSUE INDICATING THE AREA IS UNDERDEVELOPED

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 ONE WAY OF CONSIDERING TREATMENT IS TO THINK OF DEVELOPMENT AS OCCURRING EASIEST DURING CERTAIN PERIODS OF LIFE OFTEN CALLED “CRITICAL PERIODS” › CHILDHOOD AND EARLY ADOLESCENCE MAY BE A WINDOW FOR DEVELOPING SOCIAL AND COGNITIVE SKILLS WE CALL “CONSCIENCE”

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 HARE’S STUDIES SHOW THAT GROUP THERAPY FOR PSYCHOPATHS IN PRISON RESULTS IN MORE CRIMES THAN IF THEY HAD NO THERAPY. › NOTORIOUSLY GOOD AT LEARNING AND EXPLOITING THE WEAKNESSES OF OTHERS › THEY HAVE TROUBLE ABSOBING ABSTRACT IDEAS SO LECTURES ABOUT PERSONAL RESPONSIBILITY ARE UNLIKELY TO BE HELPFUL  INSIGHT ORIENTED THERAPY ALSO INEFFECTIVE

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 “ We found the more mindful you are, the more activation you have in the right ventrolateral prefrontal cortex and the less activation you have in the amygdala. We also saw activation in widespread centers of the prefrontal cortex for people who are high in mindfulness. This suggests people who are more mindful bring all sorts of prefrontal resources to turn down the amygdala.”

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 What is the function of self-injury? › Did patient want to die?  Usually “No” › A way to tolerate inescapable and unbearable emotions, most often intense anxiety  Stuck in a bad situation and cannot find another way to cope › Self-injury is reinforced to the extent the behavior is effective

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 Self-injury is reinforced to the extent the behavior is effective (continued)  Both positive and negative reinforcement  Negative reinforcement is rewarding by making and unpleasant situation stop  Positive reinforcement is rewarding by gaining something after the behavior  When negative reinforcement generally relieves uncomfortable emotions like anger, anxiety, guilt and numbness  When positive reinforcement includes “feeling something even if it is pain”, punishing oneself and feeling relaxed

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 WITHOUT CONSCIENCE: THE DISTURBING WORLD OF THE PSYCHOPATHS AMONG US. ROBERT D. HARE. GUILFORD PRESS,  SUFFERING SOULS: THE SEARCH FOR THE ROOTS OF PSYCHOPATHY. JOHN SEABROOK IN NEW YORKER, PAGES 64-73; NOVEMBER 10,  INSIDE THE MIND OF A PSYCHOPATH. KIEHL AND BUCKHOLTZ. SCIENTIFIC AMERICAN MIND, PAGES 22-29; SEPTEMBER/OCTOBER 2010.